Can South Africa Reach the End TB Goals?

Tuberculosis remains a major public health challenge in South Africa, and the country’s National Tuberculosis (TB) Programme has committed to the World Health Organization’s End TB Strategy targets: an 80% cut in TB incidence and a 90% cut in TB deaths by 2030 compared with 2015. Mmamapudi Kubjane and colleagues were asked to examine whether reaching those targets is realistic under the 2023–2028 National Strategic Plan for TB (NSP) and what it would cost. The researchers looked at a package of interventions that the NSP prioritizes: expansion of TB preventive therapy (TPT), symptom screening at primary health clinics, testing with Xpert for people who are symptomatic, screening of household contacts, community-based screening (door-to-door and digital chest X-ray), and targeted universal testing for TB (TUTT) among people living with HIV (PLHIV), household contacts and those with prior TB. They also considered efforts to reduce initial loss-to-follow-up (ILTFU). Beyond the NSP, two aggressive hypothetical “Max” scenarios were modelled to see whether more intense screening and prevention could push South Africa to the End TB goals.

To estimate impact and costs, the team used the Thembisa TB model together with public-sector cost data, calculating incremental cost-effectiveness as cost per life year saved (LYS) across scenarios from 2023 to 2042 (and in some comparisons to 2043). The NSP scenario produced substantial gains: a 44% reduction in TB incidence and a 55% reduction in TB mortality by 2030 relative to 2015. The two aggressive scenarios—called Max 1 and Max 2—did better on incidence (57% and 56% reductions) and achieved larger mortality reductions (75% and 71%), but still did not meet the End TB targets. Looking at value for money, TPT for PLHIV and Xpert testing for symptomatic care seekers were cost-saving over 2023–2043. The most cost-effective individual actions included symptom screening for household contacts ($12/LYS), ILTFU reduction ($13/LYS), TUTT for household contacts ($84/LYS), and TPT for household contacts ($106/LYS). Overall, compared with baseline the NSP increased costs by 57% while saving 6.6 million life-years at $308/LYS. Max 1 raised costs by 329% and saved 16.5 million life-years at $712/LYS; Max 2 raised costs by 1526% and saved 14.6 million life-years at $3,774/LYS.

The study’s bottom line is both hopeful and sobering. Scaling up the NSP interventions would save millions of life-years and substantially reduce TB illness and deaths, and some actions—especially TPT for PLHIV and wider use of Xpert—are cost-saving. But even aggressive screening and prevention scenarios examined here would not achieve the WHO End TB targets by 2030. That gap matters for policy: moving farther will require finding efficiencies in how current interventions are delivered, targeting the most cost-effective elements such as household contact screening and reducing ILTFU, and investing in new tools. The authors point to the need for low-cost diagnostics and effective TB vaccines as likely essential ingredients to accelerate decline. In short, the NSP represents important progress, but additional innovations and smarter delivery will be required to reach the End TB goals.